PROJECT SUMMARY Colorectal cancer (CRC) is a leading cause for cancer-related mortality in the United States (US), but screening is underutilized, especially in low-resource settings and among low income populations. Federally Qualified Health Centers (FQHC) are government-funded facilities that provide access to healthcare for millions of low-income Americans each year and frequently use low-cost, non-invasive CRC screening modalities like the fecal immunochemical test (FIT) to maximize screening participation. A major challenge for FIT-based screening programs, however, is that positive FIT results are common (5-14%) and warrant subsequent follow-up with diagnostic colonoscopy to assess for precancerous or cancerous lesions and avoid poor CRC outcomes. In FQHCs, only 40% to 58% of patients complete colonoscopic follow-up after positive FIT, which reflects a lack of clinical resources and optimal system processes to facilitate access to and patient utilization of diagnostic colonoscopy. The Northeast Valley Health Corporation (NEVHC) is one of the largest FQHCs in the nation and is comprised of 14 integrated community-based facilities that serve primarily low-income and uninsured racial and ethnic minorities. The proposed study aims to extend an existing partnership between the University of California Los Angeles (UCLA) Center for Cancer Prevention and Control Research (CPCR) and NEVHC to identify deficiencies in clinical care processes required to achieve colonoscopic follow-up after positive FIT. The specific aims of the study are: 1) to use electronic medical record data to perform an in-depth evaluation of the clinical processes between the identification of a positive FIT and completion of colonoscopy at NEVHC and to determine the rate of completion and time to completion for each step in the clinical pathway (e.g. patient notification of positive FIT result, colonoscopy referral); and 2) to conduct structured interviews with NEVHC patients and providers and gastroenterologists to understand their perspectives on barriers and facilitators to the clinical processes following a positive FIT. The proposed study fills an important gap in our understanding of the system-level processes that may facilitate or impede completion of diagnostic follow-up after a positive FIT result. Improving follow-up of abnormal CRC screening is highly responsive to the National Cancer Institute Cancer Moonshot goals, the 80% by 2018 CRC screening campaign, and other national calls to action regarding CRC screening. The information gained from our project will serve as the foundation for the development of interventions to improve rates of colonoscopic follow-up after positive FIT for at-risk, low income and minority patients in low resource settings.